John R. Hatzenbuehler

Risk modifiers for concussion and prolonged recovery

Context: Currently, no consensus exists for grading the severity of concussions. Identification of risk factors that may affect concussion risk and the likelihood of prolonged recovery can be of value to providers who manage concussion. Evidence Acquisition: Relevant studies were identified through MEDLINE (1996-2011) using the keywords concussion, postconcussive syndrome, and risk or risk factor. Targeted searches for specific risk factors were conducted with additional keywords, such as gender and migraine. Manual review of reference lists was also performed to identify pertinent literature. Results: For risk factors of concussion, history of prior concussion and female sex have the most supporting evidence. Sports with consistently high risk for sustaining a concussion include football, men’s ice hockey, and women’s soccer. Younger athletes appear to be more susceptible to concussion, but data are limited and inconsistent. Protective equipment does not definitively alter concussion risk, though it protects against other injuries. Symptoms such as long headaches, migraines, amnesia, and multiple symptoms appear to be associated with prolonged recovery. Younger age may also increase the risk of prolonged concussion. Conclusion: High-quality evidence for risk modifiers in concussion remains sparse. Prior concussion, collision sports, female sex, and women’s soccer are the strongest known risk factors. Evidence for most other factors is inconclusive.

AMSSM scientific statement concerning viscosupplementation injections for knee osteoarthritis: importance for individual patient outcomes.

Osteoarthritis (OA) is a disabling disease that produces severe morbidity reducing physical activity. Our position statement on treatment of knee OA with viscosupplementation injection (hyaluronic acid, HA) versus steroid (intra-articular corticosteroids, IAS) and placebo (intra-articular placebo, IAP) is based on the evaluation of treatment effect by examining the number of participants within a treatment arm who met the Outcome Measures in Rheumatoid Arthritis Clinical Trials-Osteoarthritis Research Society International (OMERACT-OARSI) criteria, which is different and more relevant than methods used in other reviews which examined if the average change across the treatment groups were clinically different. We performed a systematic literature search for all relevant articles from 1960 to August 2014 in the MEDLINE, EMBASE and Cochrane CENTRAL. We performed a network meta-analysis (NMA) of the relevant literature to determine if there is a benefit from HA as compared with IAS and IAP. 11 papers met the inclusion criteria from the search strategy. On NMA, those participants receiving HA were 15% and 11% more likely to respond to treatment by OMERACT-OARSI criteria than those receiving IAS or IAP, respectively (p<0.05 for both). In the light of the aforementioned results of our NMA, the American Medical Society for Sport Medicine recommends the use of HA for the appropriate patients with knee OA.

Misrepresentation of Research Citations by Applicants to a Primary Care Sports Medicine Fellowship Program in the United States

Objective:To determine the prevalence of misrepresentation of publications and national presentations claimed in applications to the Maine Medical Center (MMC) Primary Care Sports Medicine Fellowship Program from 2001 through 2004. Design:A retrospective chart review study. Setting:The Maine Medical Center Primary Care Sports Medicine Fellowship Program. Methods:Presentations were confirmed in the program of the cited meeting or by contacting the sponsoring organization. Publications were verified by performing a MEDLINE search or by cross-referencing in Ulrichs International Periodicals Directory. If the title was listed, the citation was verified by contacting the publisher. Results:Fifty applicants reported research publications. Of those, 14 applications had publications that could not be verified. The overall misrepresentation rate was 11.3%; among applicants claiming publications it was 28%. There was no difference in misrepresentation rate between specialties. Eighteen applicants reported giving national presentations, and nine presentations could not be verified, corresponding to an overall misrepresentation rate of 5.6%. Of applicants claiming presentations, 38.9% had at least one misrepresentation. Conclusion:Applicants to the Maine Medical Center Sports Medicine Fellowship Program were found to have high rates of misrepresentation in their citations of both publications and presentations.

AMSSM Scientific Statement Concerning Viscosupplementation Injections for Knee Osteoarthritis: Importance for Individual Patient Outcomes.

Objective:Osteoarthritis (OA) is a disabling disease that produces severe morbidity reducing physical activity. Our position statement on treatment of knee OA with viscosupplementation injection [hyaluronic acid (HA)] versus steroid [intra-articular corticosteroid (IAS)] and placebo [intra-articular placebo (IAP)] is based on the evaluation of treatment effect by examining the number of subjects within a treatment arm that met the Outcome Measures in Rheumatoid Arthritis Clinical Trials–Osteoarthritis Research Society International (OMERACT-OARSI) criteria, which is different and more relevant than methods used in other reviews which examined if the average change across the treatment groups was clinically different. Data Sources:We performed a systematic literature search for all relevant articles from 1960 to August 2014 in the MEDLINE, EMBASE, and Cochrane CENTRAL. We performed a network meta-analysis (NMA) of the relevant literature to determine if there is a benefit from HA as compared with IAS and IAP. Main Results:Eleven articles met the inclusion criteria from the search strategy. On NMA, those subjects receiving HA were 15% and 11% more likely to respond to treatment by the OMERACT-OARSI criteria than those receiving IAS or IAP, respectively (P < 0.05 for both). Conclusions:In light of the aforementioned results of our NMA, the American Medical Society for Sport Medicine recommends the use of HA for the appropriate patients with knee OA.

Awareness of Altitude Sickness Among Visitors to a North American Ski Resort

Abstract Objective.—To quantify awareness of acute mountain sickness (AMS) in a sample of visitors to a North American ski resort and to identify strategies and interest for increasing knowledge of AMS in that population. Methods.—One hundred and thirty visitors to Big Sky Ski Resort, Montana, were surveyed. Demographic data were obtained. Respondents were asked about their current knowledge of AMS and then answered questions designed to quantify their depth of knowledge of the subject. Correct answers were correlated with demographic data. Respondents also answered questions indicating their interest in further education about altitude illness and their preferred modality for obtaining this information. Results.—In general, most respondents were young, 18 to 30 years (62.3%), and male (62.5%). Seventy-six percent had at least some college education and more than 5 years of skiing/snowboarding experience. Only 55% of respondents had some knowledge of AMS, but only 30% had knowledge of AMS symptoms using the Lake Louise Scoring System. About 30% knew the lowest altitude this illness can occur. There was a correlation between educational background and improved knowledge of altitude illness. Half of the respondents desired further information about AMS, and the Internet was the preferred source of information. Conclusions.—This study suggests that a large population of skiers in North America may be relatively naive to the dangers of AMS. The majority of the respondents were interested in learning more about altitude illness, and the Internet was the most attractive source of information.

Tolerability and Efficacy of 3 Approaches to Intra-articular Corticosteroid Injections of the Knee for Osteoarthritis: A Randomized Controlled Trial.

Background: Several studies have been performed suggesting that a superolateral approach to cortisone injections for symptomatic osteoarthritis of the knee is more accurate than anteromedial or anterolateral approaches, but there are little data to correlate clinical outcomes with these results. Additionally, there are minimal data to evaluate the pain of such procedures, and this consideration may impact physician preferences for a preferred approach to knee injection. Purpose: To determine the comparative efficacy and tolerability (patient comfort) of landmark-guided cortisone injections at 3 commonly used portals into the arthritic knee without effusion. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Adult, English-speaking patients presenting to a sports medicine clinic with knee pain attributed to radiographically proven grades I through III knee osteoarthritis were randomized to receive a cortisone injection via superolateral, anteromedial, or anterolateral approaches. Patients used a visual analog scale (VAS) to self-report comfort with the procedure. Western Ontario and McMaster Universities Arthritis Index (WOMAC) 3.1 VAS scores were used to establish baseline pain and dysfunction prior to the injection and at 1 and 4 weeks follow-up via mail. Results: A total of 55 knees from 53 patients were randomized for injection using a superolateral approach (17 knees), an anteromedial approach (20 knees), and an anterolateral approach (18 knees). The mean VAS scores for procedural discomfort showed no significant differences between groups (superolateral, 39.1 ± 28.5; anteromedial, 32.9 ± 31.5; anterolateral, 33.1 ± 26.6; P = .78). WOMAC scores at baseline were similar between groups as well (superolateral, 1051 ± 686; anteromedial, 1450 ± 573; anterolateral, 1378 ± 673; P = .18). The WOMAC scores decreased at 1 and 4 weeks for all groups, with no significant differences in reduction between the 3 groups. Conclusion: Other studies have shown that the superolateral portal is the most accurate. This study did not assess accuracy, but it showed that all 3 knee injection sites studied have similar overall clinical benefit at 4-week follow-up. Procedural pain was not significantly different between groups.

Unverifiable Academic Work by Applicants to Primary Care Sports Medicine Fellowship Programs in the United States

BACKGROUND In 2008, it was shown that 11% of applications to a primary care sports medicine program contained unverifiable citations for publications. In 2009, the American Medical Society for Sports Medicine changed the application requirements, requiring proof that all claimed citations (publications and presentations) be included with the fellowship application. OBJECTIVE We determined the rate of unverifiable academic citations in applications to primary care sports medicine fellowship programs after proof of citations was required. METHODS We retrospectively examined all applications submitted to 5 primary care sports medicine fellowship programs across the country for 3 academic years (2010-2013), out of 108 to 131 programs per year. For claimed citations that did not include proof of publication or presentation, we attempted to verify them using PubMed and Google Scholar searches, a medical librarian search, and finally directly contacting the publisher or sponsoring conference organization for verification. RESULTS Fifteen of 311 applications contained at least 1 unverifiable citation. The total unverifiable rate was 4.8% (15 of 311) for publications and 11% (9 of 85) for presentations. These rates were lower than previously published within the same medical subspecialty. CONCLUSIONS After requiring proof of publication and presentation citations within applications to primary care sports medicine fellowship programs, unverifiable citations persisted but were less than previously reported.

Peripheral Nerve Injury.

Anatomy Motor unit: cell body located in the anterior horn of the spinal cord, motor axon, and the muscle unit it innervates. Sensory neuron: cell body located in the dorsal root ganglion and sensory axons extending into the periphery and into the central nervous system. Endoneurium: connective tissue surrounding an individual myelinated axon. Perineurium: connective tissue binding many axons into fascicles. Epineurium: connective tissue binding fascicles into a peripheral nerve.